Effective January 1, 2021
Pharmacotherapy of Arthropathies, 5.01.550
Medical necessity criteria updated
- Actemra® (tocilizumab)
- Treatment of moderate to severe rheumatoid arthritis. Patient must have tried and failed Humira® (adalimumab) or this drug cannot be tolerated
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
Site of service review added
Medical necessity criteria updated
- Tysabri® (natalizumab)
- Second-line treatment for Crohn’s disease requires trial and treatment failure with corticosteroids, or azathioprine, 6-mercaptopurine, methotrexate, Cimzia® (certolizumab pegol), Entyvio® (vedolizumab), Humira® (adalimumab), Remicade® (infliximab), or Stelara® (ustekinumab)
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
New drug added to policy
- Ilaris® (canakinumab)
- Treatment of periodic fever syndromes
- Treatment of Still’s disease in patients age 2 and older
Pharmacotherapy of Multiple Sclerosis, 5.01.565
Site of service review added
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
New drug added to policy
Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551
Policy renamed
- From “Granulocyte Colony-Stimulating Factors (G-CSF) Use in Adult Patients” to “Use of Granulocyte Colony-Stimulating Factors (G-CSF)”
Medical necessity criteria updated
- Udenyca® (pegfilgrastim-cbqv) and Ziextenzo® (pegfilgrastim-bmez)
- As a first-line treatment for patients under age 18 who are at risk of severe febrile neutropenia
- As a second-line treatment for patients age 18 or older who are at risk of severe febrile neutropenia when Granix® (tbo-filgrastim) or Nivestym® (filgrastim-aafi) has been tried and failed, or there is a medical reason why those two drugs cannot be taken, or there is a valid medical reason why self-injection or home nursing cannot be performed
- Neulasta® (pegfilgrastim) / Neulasta Onpro®, Fulphila® (pegfilgrastim-jmdb), and Nyvepria™ (pegfilgrastim-apgf)
- As a second-line treatment of patients under age 18 who are at risk of severe febrile neutropenia when Udenyca® (pegfilgrastim-cbqv) or Ziextenzo® (pegfilgrastim-bmez) have been tried and failed, or there is a medical reason why those two drugs cannot be taken
- As a third-line treatment of patients age 18 or older who are at risk of severe febrile neutropenia when Granix® (tbo-filgrastim) or Nivestym® (filgrastim-aafi) has been tried and failed, when Udenyca® (pegfilgrastim-cbqv) or Ziextenzo® (pegfilgrastim-bmez) has been tried and failed, or there is a medical reason why those drugs cannot be taken
Effective December 3, 2020
Hematopoietic Cell Transplantation for Hodgkin Lymphoma, 8.01.29
Criteria updated
- Tandem autologous hematopoietic cell transplantation (HCT) medical necessity criteria have been removed
- Tandem autologous hematopoietic cell transplantation (HCT) is now considered investigational in patients with Hodgkin lymphoma
Miscellaneous Oncology Drugs, 5.01.540
New drugs added to policy
- Blincyto® (blinatumomab)
- Treatment of adults and children for B-cell precursor acute lymphoblastic leukemia (ALL) in first or second complete remission with minimal residual disease (MRD)
- Treatment of adults and children with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL)
- Leukine® (sargramostim)
- Treatment of acute myeloid leukemia after induction chemotherapy
- Mobilization and following transplant of autologous peripheral blood progenitor cells
- Myeloid reconstitution after (allogenic or autologous) bone marrow transplant
- Treatment for bone marrow transplant (allogenic or autologous) failure or engraftment delay
- Treatment for exposure to myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome)
Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517
New drug added to policy
- Cyramza® (ramucirumab)
- Treatment of advanced or metastatic gastric or gastro-esophageal junction (GEJ) cancer that has continued to grow while on or after prior fluoropyrimidine- or platinum- containing chemotherapy when used as a single agent or with paclitaxel
- Treatment of metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) gene changes (exon 19 or exon 21) as first-line therapy when used with erlotinib
- Treatment of metastatic non-small cell lung cancer (NSCLC) that has continued to grow while on or after platinum-based chemotherapy when used with docetaxel
- Treatment of metastatic colorectal cancer (mCRC) that has continued to grow while on or after prior therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine when used with a FOLFIRI chemotherapy combination
- Treatment of hepatocellular carcinoma (HCC) in patients who have an elevated alpha fetoprotein and have been treated with sorafenib when used as a single agent
Effective October 2, 2020
Miscellaneous Oncology Drugs, 5.01.540
New drugs added to policy
- Kyprolis® (carfilzomib)
- Treatment of multiple myeloma
- Velcade® (bortezomib)
- Treatment of multiple myeloma and mantle cell lymphoma
Pharmacotherapy of Arthropathies, 5.01.550
Site of service review added
- Avsola™ (infliximab-axxq)
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
Site of service review added
- Avsola™ (infliximab-axxq)
Pharmacologic Treatment of Infertility, 5.01.610
New policy
The following drugs have been added and may be considered medically necessary when criteria are met:
- Brand Chorionic Gonadotropin
- Bravelle® (urofollitropin)
- Follistim® AQ (follitropin beta)
- Pregnyl® (chorionic gonadotropin)
Prostate Cancer Targeted Therapies, 5.01.544
New drugs added to policy
- Jevtana® (cabazitaxel)
- Xofigo® (radium Ra 223 dichloride)
Rituximab Non-Oncologic and Miscellaneous Uses, 5.01.556
Site of service review added
- Ruxience™ (rituximab-pvvr)
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
New drug added to policy
- Avsola™ (infliximab-axxq)